The humanitarian consequences and actions in the Eastern
Mediterranean Region over the last 60 years – a health perspective
Altaf Musani1 and Irshad A. Shaikh2
1Regional Adviser; 2Medical Officer, Emergency and Humanitarian Action, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Altaf Musani: [email protected]).
Humanitarian crises – historical context
Globally, countless lives and livelihoods have been affected by the impact of natural and man-made disasters in both developed and developing countries. However, more than 90% of deaths related to natural dis- aster occur in developing countries and the economic losses in relation to GNP are far greater in developing countries as compared to industrialized ones [1]. During the period from 1984 to 2003 more than 4.1 billion people were affected by natural disasters alone [1]. The overall trend of disasters and their impact on the world clearly illustrate:
i) an exponential increase in the frequency of reported events; ii) a substantial eco- nomic burden to national economies; and iii) an increasing number of affected people who have to recover from such events.
A number of major earthquakes, floods, droughts, cyclones, conflicts and civil strife has triggered humanitarian relief to ensure the resilience in survivors. Displacement and migration are a significant consequence of disasters and have posed a new challenge to the humanitarian assistance community.
As a direct result of conflict and violence, the Office of the United Nations High Com-
missioner for Refugees (UNHCR) reports that by the end of 2007, the world’s refugee population exceeded 11 million, while 26 million people were internally displaced; an additional 25 million people were displaced because of natural disasters [2].
Recent reported natural disasters such as the South-East Asia tsunami, the cyclone in Myanmar and the earthquake in China underscore that the poor are the most vul- nerable and suffer the greatest impact. How- ever, the hurricanes that have affected the south-east of the United States of America (USA) clearly demonstrate that no nation is immune to natural hazards and disaster preparedness, across the globe, leaves much to be desired. Additionally, conflict, wars, sanctions and civil unrest have contributed to death, displacement, migration and dis- ability. The major lesson learnt from all these crises is that nations and communities must be better prepared!
Looking back at 60 years in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) there have been many types of crises, from conflict to natural disasters. Tables 1 and 2 summarize the magnitude of some of the major crises reported in the Region.
Table 1 Migration in the Eastern Mediterranean Region due to war and conflict
Country Period Refugees Internally (originating displaced persons from) assisted/protected
by UNHCR
(1993–2007)
Sudan 1963–2007 11 520 713 81 589 66 Afghanistan 1979–2007 10 3139 506 10 089 984 Iran (IR) 1974–2007 2 180 111 No data Iraq 1968–2007 17 578 886 10 974 576 Somalia 1975–2007 10 378 319 4 439 206 Palestine 1976–2007 3 471 303 No data Source: The Office of the United Nations High Commissioner for Refugees (UNHCR) Statistical online population database (http://www.
unhcr.org/statistics/45c063a82.html).
Table 2 Natural disasters and their impact in the Eastern Mediterranean Region (1950–2008) Event Country Deaths Affecteda Homeless Injured Total Damage (No.) (No.) (No.) (No.) affected (× 103
(No.) US$)
Earthquakes Iran (IR) 65 074 818 091 575 19 963 838 629 1 135 000 Egypt 20 NA NA 28 28 –
Afghanistan 2 663 152 440 6 580 5 518 164 538 340 00
Pakistan 4 989 42 975 5 200 17 605 65 780 8 255
Morocco 12 000 NA NA 25 000 25 000 120 000 Floods Iran (IR) 5 757 1 140 200 – 70 1 290 270 17 43 000 Pakistan 6 308 13 909 527 38 732 – 15 166 527 1 169 800
Yemen 657 625 000 154 750 612 907 862 1 052 900
Afghanistan 479 785 044 – 140 792 684 312 000 Sudan 130 1 847 000 30 000 – 2 877 000 25 000 Droughts Djibouti NA 255 000 NA – 255 000 – Sudan 150 000 11 850 000 NA – 11 850 000 – Somalia 19 650 1 483 500 NA – 1 483 500 – Yemen NA 2 000 000 20 000 – 2 020 000 10 000 Iran (IR) NA 625 000 – – 625 000 – Afghanistan – 48 000 – – 48 000 200
aAffected = people requiring immediate assistance during a period of emergency, it can also include displaced or evacuated people.
Source: Centre for Research on the Epidemiology of Disasters – Emergency Events Database (CRED EMDAT) (http://www.emdat.be/Database/terms.html).
NA = not available.
– = not reported.
Over the past 2 decades in particular, the Region has experienced a number of complex emergencies as well as large scale natural disasters; 15 of the 22 Member States (roughly 85% of the Region’s popu- lation) have suffered in protracted conflict situations [3]. In particular, the situations in Afghanistan, Iraq, Lebanon, Palestine, Somalia and Sudan go unabated and have collectively affected over 10 million people, 6.5 million of whom have been displaced from their homes and over 200 000 have died [4]. In Iraq, with the on-going vio- lence and insecurity coupled with previous humanitarian needs, almost a third of the country is cut off from essential health services [5]. The conflict in the occupied Palestinian territories has been ongoing for over 6 decades and still 80% of the popula- tion living in Gaza depends on humanitarian assistance. Because of the burden of these crises, the world’s highest proportion of internally displaced persons still lives in EMR.
To make matters worse, as the remain- der of the world continues to realize health gains and achievements, due to the ongoing crises in Somalia and Afghanistan, these 2 EMR countries still have the worst national records of infant and maternal mortality indicators in the world. In addition to a high frequency of natural disasters and conflict, the Region is also vulnerable because of many other factors, such as population growth (Pakistan [6] Islamic Republic of Iran [7], Yemen [8]), crop failure/food in- security (Somalia [9], Sudan [10], Afghani- stan [11], Pakistan [12]), environmental degradation (Pakistan [13,14]) and water scarcity (Yemen [15], Sudan [16], Somalia [9], Jordan [17]). These vulnerabilities to a varying degree have also contributed to rural-to-urban migration and subsequent
“premature urbanization” in major cities whereby the urban sector cannot generate
compensatory economic growth to absorb the massive influx. This has resulted in thousands living in slums and/or low in- come housing that are unsafe when it comes to natural hazards, either because of poor structural quality or risk prone locations.
Newly emerging threats in the Eastern Mediterranean Region
In addition to the aforementioned obvious and localized threats and vulnerabilities that conventionally affect the poorest members of a population, there are newly emerging threats, which include a possible human pandemic influenza, sky rocketing food and oil prices, and climate change. These are global threats and combined with the existing vulnerabilities, if left unaddressed, will result in potentially catastrophic conse- quences for marginalized populations.
Health impact of an influenza pandemic
Should the Region experience a phase 5 or 6 situation with regard to the influenza virus (evidence of significant or efficient and sustained human-to-human transmis- sion), the impact on countries could be crip- pling. Models and scenarios that have been developed on the pandemic anticipate that the health institutions will be overwhelmed with patients seeking care (at an expected attack rate of 35%, it is estimated that in the EMR, more than 180 million people will fall ill, 96–168 million will require medical care and 6–28 million will need hospitalization). Moreover, with already weakened and rundown health infrastruc- tures in places like Afghanistan, Somalia and Sudan and existing vulnerable groups, such as refugees and internally displaced populations, the pandemic influenza virus will flourish. Countries, thus, will need to
be prepared to contain the epidemic within their borders.
The Region has already witnessed the largest cluster of human cases of the highly pathogenic avian influenza virus A/H5N1 outside Asia. Out of 22 countries in the Region, H5N1 has been reported from 10, including 2 countries with H5N1 in wild and migratory birds (Kuwait and Islamic Republic of Iran), 5 with H5N1 in poultry (Afghanistan, Jordan, occupied Palestine territory, Pakistan and Sudan) and 4 coun- tries with confirmed human cases (Egypt, Iraq, Pakistan and Djibouti).
Food crisis and its impact on vulnerable populations
The world is witnessing some of the sharp- est rises in food prices ever; since Janu- ary 2008, rice prices have soared 141%.
This food inflation could push at least 100 million people into poverty (to add to the 800 million people already suffering from hunger), which will wipe out all the gains the poorest billion of the world’s popula- tion has made during almost a decade of economic growth [18]. The United Nations Economic Commission for Africa estimates that the number of food insecure people could rise by 16 million for every percent- age point increase in real prices of staple foods, meaning 1.2 billion people could be chronically hungry by 2050 [19]. In EMR, countries at highest risk from the food crisis include Somalia, Sudan, Pakistan, Palestine and Yemen. The impact is already obvious and profound. In Somalia, this has meant an additional 600 000 urban poor, a 40%
increase since January 2008, who now face conditions of acute food and livelihood crisis and humanitarian emergency and are in need of assistance [8]. In the case of Palestine, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) reports that whereas
in 2004 it spent about US$ 8 per refugee every 2 months in Gaza, today costs have risen to US$ 19 to provide the same 60%
of their basic needs, these increases have forced the agency to significantly reduce the number of recipients of aid [19]. Ad- ditionally, the global food crisis threatens to spark even more violence and social unrest in war zones where millions of already marginalized people have had no or very limited success in their efforts to secure access to sustainable food commodities. It is therefore crucial that the health sector is able to respond quickly to excess violence and injury.
Climate change and its humanitarian impact
Climate change is expected to trigger, com- pound and increase disasters and exacerbate existing humanitarian situations. Most of the effects of climate change will be on low income, resource-starved countries with limited ability to adapt and respond.
Extreme events such as changes in rain patterns, more severe tropical cyclones, drought, floods, extreme temperature fluc- tuations, possible rise in sea levels, coastal erosion and reduced biodiversity are ex- pected to have a broad-ranging influence on agricultural production, food security, access to water, habitat and livelihoods.
Likewise, there would be a considerable impact on human health. Scientists consider that most of the health impacts of climate change would be adverse. WHO, in its World Health Report 2002 [20], estimated that climate change was responsible in 2000 for approximately 2.4% of worldwide cases of diarrhoea and 6% of malaria in some middle-income countries. According to a World Bank study [21], just a 1 metre rise in sea levels would turn at least 65 million people in the developing world into envi- ronmental refugees; in terms of number of
populations affected, the top 10 countries in such a scenario include 3 countries from EMR: United Arab Emirates, Egypt and Tu- nisia. From a water scarcity perspective as a result of climate change, again, the Mediter- ranean and the Middle East Regions are the ones expected to be the worst off. The high number of refugees and internally displaced people indicate the existing vulnerabilities in EMR; because of these, greater humani- tarian efforts will be required to deal with the consequences of climate change in order to prevent further erosion of their capacity to cope.
Responding to Regional crises
The inherent hazards and vulnerabilities that have been faced over the past 60 years in EMR, coupled with emerging threats, clearly indicate the changing nature and dy- namics of humanitarian crises. It is apparent therefore that humanitarian strategies and methods used to deal with crises will need to be significantly different from the verti- cal relief approach of the present. Emerg- ing causes of humanitarian crises – human pandemic influenza, climate change, food insecurity or bioterrorism – require multi- disciplinary and multisectoral prevention and preparedness measures to build, sustain and promote national and local capacities.
Moreover, the position of health, although clearly linked to better quality of life and livelihood, has often taken a back seat com- pared with the models and operations for food aid and water distribution. Hence the challenge for WHO, ministries of health and health partners in the humanitarian arena is to promote a public health preven- tive approach before disasters occur as well as to ensure that public health best practices apply in times of crises in order to ensure human survival.
Over the last 30 years WHO’s humani- tarian response actions and policies in the Region have focused on relief aid and en- suring the availability of and access to health services for those most in need. The approach was challenged by a number of major emergencies in the past that required WHO to become more involved in op- erations while still maintaining its technical leadership in health. As the frequency of natural and man-made disasters has in- creased, WHO has gradually evolved to be an active humanitarian partner among the international aid agencies. However, the technical leadership and health guidance to work with national and international partners and promote standards in health assistance still remain a core strength of the Organization. The role of WHO as the leader in health and humanitarian assist- ance has been echoed and re-enforced by Member States and partners through several World Health Assembly resolutions. More recently the humanitarian reforms have thrust WHO to the fore as the “convener”
of the global and country health clusters in times of emergencies [22].
Over the last 2 decades WHO has been challenged by several emergency situa- tions requiring the provision of health and humanitarian assistance to affected popula- tions. Establishing operational capacity to respond to the earthquakes in the Islamic Republic of Iran and Pakistan as well as the conflict/violence in Lebanon, Iraq, Somalia, Afghanistan and Sudan has been a driving force behind WHO’s regional response activities; however, more recently a strong shift from purely response to include and integrate preparedness and risk-reduction measures has been addressed within the Or- ganization’s strategy. Additionally, WHO is tackling the aspect of health in a post-crisis phase in order to ensure the bridge between relief and development.
What does the future for hold for the Region with regard to crises? The newly emerging threats coupled with the long- standing and inherent vulnerabilities do not present an optimistic prospect for health in the Region. Despite tremendous efforts to increase emergency response measures to safeguard lives and livelihoods, humani- tarian partners, and in particular Member States, will have to intensify efforts to deal with the growing demand for humanitarian assistance. WHO has attempted to respond to the call of Member States for investment in national and local capacities for disaster preparedness and response. Ensuring the in- tegrity and resilience of the health system in times of crisis has been the focus of a recent World Bank, United Nations International Strategy for Disaster Reduction and WHO global campaign of hospitals safe from disasters [23].
Additional challenges facing humanitar- ian assistance were outlined in a recent report of an interagency standing committee and addressed a number of key factors that we must take into consideration [24]. These
include the ever-evolving and negotiating space for provision of humanitarian assist- ance; the global nature of various crises, such as a possible pandemic; greater en- gagement of local and national partners, including the private sector; use and en- gagement of national and foreign military assets in humanitarian crises; the erosion of protection of humanitarian workers; and the increased need for accountability by the humanitarian community.
EMR, despite its richness, heritage and diversity, has been beset by crisis situations for decades. Although there may have been several milestones in health throughout the Region, countries like Somalia, Af- ghanistan and Sudan stand on a precipice and risk falling deeper into poverty and ill health. Beyond the long-standing conflicts in the Region, all countries are vulnerable to impacts of climate change which threaten development and prosperity. Our challenge, if we are to reach the targets of the United Nations Millennium Development Goals, is to ensure the resilience of nations and com- munities to the effects of disasters.
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